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r o TOWN OF YARMOUTH i l
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N "4:... g Application$ for a Permit to Build No. gi v
UPON FINAL APPROVAL MAP kO‘__ LOT /'1-3-1
FEE MUST ACCOMPANY THIS APPLICATION. DATE /d/2.299�
The undersigned hereby applies for a permit to build /61/42.2. 19
acc rding to the following specifications
X. Name of property owner �flN c• S 4\C")e ,cc-NCiTel. '?--\'? n
Address VS--4 Cn\cmc. z \ , •-4‘9cM0,1.\'YX
ame of Architect(if any)
2ameof
Tel.
builder ""qac.�o ` ,�.V",Q&crf'tN. Address '1/4.4:::i c Thr•. r k
4. License No. Tel.
5. Name of Mason Address
6. License No. Tel.
7. Construction address Simi/ /03 1-2-7/2-1/X-44-1" C/&4 '
Flood // District R yo
8. Date of subdivision Approval plain zone Zone
9. Private dwelling 0 /Estimated Cost DO NOT WRITE IN THIS SPACE
10. Multi family 0 !,5-5Z .- Srt,p' r?r#eern Type of room No.
rnere _sttg_Thain /an?,se_
11. Commercial ❑Ari Il°d 1. l Kitchen
12. Other . 0 '' . / i Dining Rm.
13. No. ofistrict SI
''?S i Cry Living Rm.
Bed Rm. .
14. Foundation - Full 0 Half 0 Crawl 0 Slab ler Bath
15. Materials - Wood 0 Cement 0 Other 0 Deck
16.Type of heat - Oil 0 Gas 0 Electric 0 Other 0 Closed porch
17. Garage - 1 ❑ 2 ❑ Family Rm.Sun room
18. Swimming pool - Size Garage
19. Storage shed - Size Shed
20. Stove - Wood 0 Coal 0 Alterations
21. Size of lot: No. of feet front No. of feet rear No. of feet deep
22. Size of building. No. of feet front No. of feet side No. of feet rear
23. Distance from nearest building: Front Ft. side Ft. side Rear
24. Distance back from line or street From rear lot line Side line
25. H.I.C.R. No. --------ii�,rc� ,�,s�rircrr•A. (C)A
LOT RELEASED BY Signature
PLANNING BOARD Address
Date
TOWN OF YARMOUTH
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE c c ZZ,\Reto
JOB LOCATION \IC:5-4 vntC(\ SS"Z' �`oScYCk Ne\
NUMBER STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" tq,Mp s K e` v'er ?!'o'Z"M'3
NAME HOME PHONE WORK PHONE
. PRESENT MAILING ADDRESS �M.Q •
CITY OR TOWN STATE ZIP CODE
THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER-
OCCUPIED DWELLINGS OF ONE OR TWO UNITS AND TO ALLOW SUCH HOMEOWNERS TO
ENGAGE AN INDIVIDUAL FOR HIRE WHO DOES NOT POSSESS A LICENSE, PROVIDED
THAT SUCH HOMEOWNER SHALL ACT AS SUPERVISOR. (STATE BUILDING CODE SEC-
109.1.1 )
DEFINITION OF HOMEOWNER:
PERSON( S) WHO OWNS A PARCEL OF LAND ON WHICH HE/SHE RESIDES OR INTENDS TO
RESIDE, ON WHICH THERE IS, OR IS INTENDED TO BE, A ONE OR TWO FAMILY
ATTACHED OR DETACHED STRUCTURES ASSESSORY TO SUCH USE AND/OR FARM
STRUCTURES. A. PERSON WHO CONSTRUCTS MORE THAN ONE HOME IN A TWO-YEAR
PERIOD SHALL NOT BE CONSIDERED A HOMEOWNER, SUCH "HOMEOWNER" SHALL SUBMIT
TO THE BUILDING OFFICIAL, ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL,
THAT HE/SHE SHALL BE RESPONSIBLE FOR ALL SUCH WORK PERFORMED UNDER THE
BUILDING PERMIT. (SECTION 109.1.1 )
THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH THE
STATE BUILDING CODE AND OTHER APPLICABLE CODES, BY-LAWS, RULES AND REGU-
LATIONS.
THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS THE TOWN OF
YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIRE-
MENTS AND THAT HE/SHE WILL WI SAID OCEQD�IRES AND REQUI • a i NTS.
i�t
HOMEOWNER'S SIGNATURE n "1*€ 12o t. crr�C1NN
APPROVAL OF BUILDING OFFICIAL
•
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked y , please indicate the type coverage by checking the appropriate box.
A liability Insurance policy 0 Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE•WAIVER:1 am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner lci— Agent 0
Signature of Owner or Owner s Agent
•
•
43
A =a-r it a- COMMONWEALTH OF MASSACHUSETTS
• DEPARTMENT OF INDUSTRIAL ACCIDENTS
VC:cdf 600 WASHINGTON STREET
games Camooeu BOSTON, MASSACHUSETTS 02111
romm:ssoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
I,
(licensee/permittee)
• with a principal place of business/residence at
(City/State/Zip)
- do hereby certify, under the pains and penalties of perjury.that: - - - - -
[) I am an employer providing the following workers' compensation coverage for my employees working on this
job.
Insurance Company Policy Number
[) I am a sole proprietor and have no one working for me.
[ j I am a sole proprietor, general contractor or homeowner(circle one)and have hired the contractors listed below • -
who have the following workers' compensation insurance policies: • ,1- • . . .
Name of Contractor Insurance Company/Policy Number . . .
•
h
Name of Contractor - Insurance Company/Policy Number . • - - • • • -•
•
•
Name of Contractor Insurance Company/Policy Number .. -
'Kam a homeowner performing all the work myself.
NOTE.Please be aware that while homeowoers who employ persons to do maintenance,construction or repair work on a
dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(GL C. 152,sect. 1(5)),application by a homeowner for a license
or permit may evidence the legal status of an employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for coverage
verification and that failure to secure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties
• consisd"ng of a fine of up to SI500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop'Work Order and a
fine of 5100.00 a day against me.
Signed this Sezorxc day of oe 'QV , 1919.
LicenseeiPermirtet- Licensor/Permittor
Suggested Affidavit for Home Improvement Contractor Permit Application:• . .- _ -
For Omce Use Only NAME OF CITY/TOWN •
Permit No. . . •
Date
Alt1DAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGLc.142A requires that the"reconstruction,alteration,renovation.repai jmoderniration,conversion,inprovement,removal,demolition,
or construction Man addition to any pre-existing owner-occupied building containing at least one but not more than Cour dwelling units....or
to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: 'R? • f CCC Est. Cost 2 ctIO
Address of Work c' C
Owner Name: .'QS`n2 . \\P
Date of Permit Application: ce It 27, kg 9Th
I hereby certify that:
Registration is not required for the following reason(s): •
_Work excluded by law
Job under 51,000
_Building not owner-occupied
�it7wner pulling own permit
_00ther (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO-NOT HAVE
' ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL •
.
c. 142A
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
•
OR:
Notwithstanding the ab�ove notice^. X. he thy ap ly fora permit as the,p vner of the above property:
oc� Az2 eke % v c�
Date Owner Nln�
•
•
•
•
•
•
In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit •
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S
• 150A.
The debris will be disposed of in:
•
•
1:3K r \ ac..D
(Location o Facility)
•
•
•
gZSSignature of it Applicant
ZZ.\RRTh
Date
o;::N N • ..
piRN CENN�"S,t p'p NS _ .
• 1 fP
/- • `; Old Kings Highway Regional Historic_District Committee I,
in the Town of Yarmouth fora i
I•
,4 " CERTIFICATION OF EXEMPTION
1
' ,;Application Is hereby made, in triplicate, for the issuance of a certificate of exemption under Section 6 and 7 of Chapter 470,
Acts and Resolves of Massachusetts, 1973, as amended for proposed Work as described below and on plans, drawings, or photo-
graphs accompanying this application.
TYPE OR-PRINT LEGIBLY • DATE I t)' I c - r 3
ADDRESS OF PROPOSED WORK Io 3 ()Ali e)A) 'f r ` . (00 kr ASSESSORS MAP NO. 103
I
OWNER l Amo j 1.)e C n1 �,f l\ ASSESSORS LOT NO. tJ_ 3 I '
HOME ADDRESS 1 () is thy( Ur\) ct TEL. NO. 5 (1c 34,2 . 3156 1
I
AGENT OR CONTRACTOR �' s• ''' k S Wt Z2 UJ lsr y
ADDRESS f 01 UNt,t:•u St \( . f)t,r�`t- Itetr\ TEL NO- -7.1TC - f 3 c
This application is for exemption of proposed exterior`lconstruction on the ground that:
❑ (1) It will not be visible from any way or public place.
(2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission.
(Check applicable box)
PROPOSED WORK: Describe and furnish plan of proposed work, showing location on lot, and, if an addition is involved, show-
ing location of existing building.// l C65(ili
f! 1}. J}',"� ii• O`I'i- -Z,.� fS-i~r.,� �l2oc -� l�(eNa ;J:J 1- R1 �1
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APPROEp •
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HMQjEM
'
..17.-5
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jJ� ift SIGNED 4-v.0-"\W1S I'M �Ptdjj,`/ tOf, ,
1,t,.i � .z....1 Owner-Contractor-A2ent
Space below`lfne for Commute:Pk.
• n /� - .
Received by H.D.C. The Certifire cate is hereby, _
Date inl/f/7� f (:l..-�/ 2.Ai
//j / - ,< ,&‘...-\• ,��.".—�...•�
/,/ /%
7/7 "F, CTime / ,��9 :,-.-ger /,",�
By
an". . . - Date . / ` C Cis'//f -j- -
e
't,�� [�'...�c.
Approved 'y The categories of work entitled to exemption are listed on
Disapproved 0 the back of this form,
,:g1EXTERIOR ARCHITECTURAL FEATURES a •
SUITABLE FOR CERTIFICATES OF EXEMPTION
.
' FOR RESIDENTIAL USE ONLY - - - 1,
.
•
EENCES:, 1. Pogt and rail, split, half round or round; natural finish
i•t 2. Square rail;white or natural finish .
` ,, 3. Stockade; natural or gray stain finish; not forward of face of main building
4. Picket;white only _
• (Maximum height of all fences:4 feet)
. :r
HEDGES': natural, not to exceed four feet in height
DECKS: constructed of wood, on single family dwellings, built after 1900, at first floor level, at the rear only,
railings not to exceed 36 inches in height, not over 50% to be visible from a way; natural finish or color
compatible with building involved • ,a., • • !.
BREEZEWAYS: enclosure of existing breezeways, consistent with style, material and color of house, excluding sliding
glass doors facing street,way or public place .
FLAGPOLES: on residential property, not over 24 feet high, not less than 20 feet from way, constructed of wood, with
natural finish or painted white, or of aluminum, or of fiberglas or metal painted white
ARBORS AND TRELLISES: of lightweight, wooden construction, not over nine feet high
f ,
ROOFS: natural cedar shingles, or asphalt shingles per approved color samples; not over five inches exposure to
weather
SIDING: natural cedar shingles, or wooden clapboards -natural or approved color; not over five incnes exposure
to weather �(\
STORM SASH, STORM DOORS,WINDOW SCREENS, SCREEN DOORS, GUTTERS AND LEADERS: permissible if
consistent with style, material and color of building .
LIGHT POST: permissible if consistent with style, material and color of building '1.--
AIR CONDITIONERS: portable, I window units at side or rear of building
STONE WALLS:'•construction of field or split stone, not exceeding 30 inches in height __
v. ...
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NOTE • •
.', 1. All prior bulletins hereby superseded. • . . .
•
y
2. Conditions contained in certificates of appropriateness shad be binding regardless of_any exemp:-tns container herein.